Understanding Concussions
18 May 2016

Part I:Taking It On The Chin - Sidelined by Concussion , Athlete Urges Awareness

Nick Delande will never forget Sept. 28, 2015. That was the day the Monomoy High School student athlete suffered an injury during a soccer game that not only left him with a broken jaw, but also a concussion so severe it sent him into a months-long ordeal that ultimately forced Nick to withdraw from school during his senior year.

"On Sept. 28 we were playing Hull," said Nick, a goalie and captain for the Monomoy boys varsity soccer team. "It was my fifth game, I believe. It was 10 minutes into the game and I had the ball in my hands. A kid was in a sprint, and he hit me with a knee right in the jaw, which broke on both sides."

Though aware that he was injured, Nick's first instinct was to get back in the game. Then he began to understand how serious his injuries were.

"I was very dizzy," he said. "At first I didn't really know where I was."

According to Nick, the Hull athletic director initially believed that he had suffered a muscle strain or a bad bruise, but it soon became apparent that Nick's injury was much worse.

Nick was sidelined and a decision made to have him remain at the game and travel home on the bus with the team. It was on that ride that the magnitude of Nick's injury became apparent.

"I called my parents crying," he said. "I was just really, really emotional. On the bus ride home I got really tired and cried at least 10 times. Then I'd stop, but then all of a sudden I would cry again."

Given that Nick is not typically an emotional person, his crying was the first indication that there was a more serious problem than a broken jaw. In the days that followed the injury, Nick and his family learned that along with the broken jaw, he had suffered a severe concussion .

According to Dr. Andrew Judelson, Director of the Sports Concussion Clinic at Spaulding Rehabilitation Hospital Cape Cod in Sandwich, concussion injuries are the most common neurological injury in sports, accounting for roughly 15 percent of all high school sports injuries, and approximately 90 percent of all high school head injuries.

"I make sure that everybody that I meet with hears me say that concussions are a form of brain injury," Judelson said. "For too long we talked about, 'I got a ding. I got my bell rung.' Those descriptive terms really don't mean anything to anybody, and I think downplay the significance of what the concussion is." Judelson said that a concussion is a functional impairment of how the brain works. Symptoms vary from person to person, but might include physical, cognitive, sleeprelated, and emotional issues. For Delande, certain effects were immediate.

"I was very dizzy," he said. "At first I didn't really know where I was. I knew I had a concussion because I'd had one a couple months prior, but this one was a lot worse."

When Nick's father, Bill, met his son at the bus upon the team's return from Hull, he knew immediately his son was in trouble.

"I knew right away that there was a lot more going on than just a bruised jaw," said Bill. "He could hardly talk right. He was very, very emotional, which is very unlike him. He wasn't walking straight. He could barely stand up. He was a mess. Right off the bat I said, 'we're going to the emergency room.' I knew it was going to be a long night."

Nick was eventually sent to Children's Hospital in Boston for treatment of his jaw. Once surgery to repair Nick's broken jaw was complete, requiring his jaw be wired shut for four weeks, doctors addressed the concussion . Although Nick was cleared to return to school, he quickly learned that he was in for an uphill battle.

"I got a headache within the first 10 minutes, and then I just got really tired. I couldn't focus, I couldn't do anything," Nick said. "My vision was really blurred. My vision was what was affected the most from this. My eyes wouldn't converge. My left eye was a lot slower than my right, and so my eyes weren't working together and that's what made everything so much harder. Looking up and down, looking across the room, looking everywhere, it just gave me a headache right away. That's when I knew I had to go home."

Four weeks later, Nick was still having major issues with symptoms and was still unable to attend school. He was referred to Dr. Judelson for further evaluation.

"Nick had a lot of difficulty with a lot of different things," Judelson said. "In particular when we looked at how Nick's eyes would focus on an object far away when it moved closer to him, or if Nick was scanning, whether he held his head still or whether he moved his head, all of those things disrupted him. So that made me concerned about vision, vestibular problems contributing to his headaches."

Basically, Nick's eyes were no longer working in sync, which made reading and following along in a classroom incredibly difficult and often resulted in painful headaches. Judelson prescribed medication to help Nick sleep, since that was also disrupted, and enrolled Nick in physical therapy to help with balance, eye and headache issues. He also set him up with a neuro-optometrist who provided Nick with special glasses to use while his eyes recover. Unfortunately for Nick, his symptoms were still problematic enough that attending school was an immense challenge and he was ultimately forced to withdraw.

"I unfortunately got told a few weeks ago that I am unable to graduate, so I have to repeat my senior year," Nick said. "Everything is medically cleared, but I was only here for 28 days."

The news was bittersweet for Nick and his dad.

"The senior year is supposed to be the best year," said Bill. "It was the best year of my life. Senior year is awesome, especially when you play sports. [Nick was] the captain of the soccer team, and he didn't really get to enjoy any of it."

It is hoped that because his withdrawal from school was due to medical reasons, Nick will be able to resume playing soccer and basketball next school year, though the idea of his son stepping back on the soccer pitch does give Bill Delande pause. Because he knows well his son's passion for the game, however, Bill said he supports Nick in his desire to play.

"The hardest part [was] my wife and I sitting on the sidelines and seeing him have to sit there," Bill said. "That sucked because we knew how much he wanted to be out there."

Nick's more pervasive concern is people confused about why he's repeating his senior year.

"People are going to look at me like I'm the fifth year senior. I don't want to be looked at like that at all," Nick said. "I think people need to realize that I can't go to school because of my concussion and that I'm coming back next year because of my concussion . It's not something I wanted to do; it's not something anyone wants to do. I think they just need to realize that I'm here for a reason and should be accepted like everyone else."

The inherent problem is that concussion injuries are largely invisible, so there is a tendency by parents and teachers to assume a student is "faking it." Judelson cautions against that mentality since in spite of the invisibility of the issue, concussion injuries are not to be taken lightly.

"I like to think about the symptoms happening because my brain's not able to provide the energy that it needs to cope with whatever the issue may be," Judelson said. "[For example, a kid says] 'I was trying to read for 10 minutes.'Well, that task may require more energy than their brains are able to handle at this point."

The ideal means of recovery for someone with a concussion injury is rest, and for more severe symptoms that last more than a few weeks, medical intervention. Sadly, in terms of prevention, short of someone locking themselves in a safety bubble for life, not much can be done, though Judelson encourages the young athletes he sees to wear protective gear whenever possible.

"Unless we're going to take away all contact sports and all chance of any accident ever happening - slip, trip fall - it's hard to completely erase all that," Judelson said. "I don't know why you wouldn't put on some of the protective headgear that they now make for soccer. They're not concussion proof, but they may provide a little bit more protection and a little bit of force dissipation so whatever the blow to your head is, it hurts less. There's less energy transmitted to your skull, to your brain, and maybe that makes the difference between having symptoms and not."

Seven months after Nick's initial blow to the head, he is largely symptom free, save for some lingering sleep issues, and is hoping to play summer soccer with a local league. He is sharing his experiences in the hope of raising awareness as to the seriousness of concussion injuries.

"I kind of looked at like I didn't think anything of it," Nick said. "I didn't think concussions were a big deal. I thought you'd just get headaches and they'd just go away. But after this one, I look at it totally differently. I take concussions seriously, and everyone else should. It's not something to be played with."

Part II:

More Than Just a Hit To The Head: - Why Concussion Injuries Should Be Taken Seriously

Each time a student athlete steps into a game, their parents feel a sense of anxiety given the risk of injury, no matter the sport. That can include anything from a sprain to a broken bone, but the most prevalent injury seems to be concussion , something doctors, coaches, parents and players are learning can be far more than just a simple hit to the head.

"Concussion is the most common neurological injury in sport," said Dr. Andrew Judelson, physiatrist and director of the Sports Concussion Clinic at Spaulding Rehabilitation Hospital Cape Cod. "It accounts for about 15 percent of all high school sport-related injuries, and 90 percent of all high school head injuries."

According to Judelson, as well as the website HitsToThe-Head.org, the Centers for Disease Control estimates close to four million concussions a year. The sports with greatest risk are football, particularly for young men, and, for young women, soccer, with the majority (78 percent) of concussion injuries in high school sports happening during game play.

Monomoy student athlete Nick Delande was one of several soccer players to suffer a serious concussion during an early season game, with his symptoms necessitating he withdraw from school and repeat his senior year. He shared his story in last week's Cape Cod Chronicle, and said he feels strongly that people need to better understand concussions and the risks they pose. Judelson agrees.

"I make sure that everybody that I meet with hears me say that concussions are a form of brain injury," Judelson said. "For too long we talked about, 'I got a ding. I got my bell rung.' Those descriptive terms really don't mean anything to anybody, and I think downplay the significance of what the concussion is."

Judelson explains that "a concussion is a functional impairment of how the brain works."

"It's important to note that it's a functional problem," he said. "There are no structural changes, or shouldn't be any structural changes with a concussion ."

To help with better understanding of what transpires during a concussion , Judelson offered a description.

"The brain is a Jello-like, visco-elastic material, surrounded by a layer of fluid and living in this solid box that we call our skull," he said. "When our brain and skull are moving together like they typically do, at the same rate, there are no problems. The issue becomes when your skull stops all of a sudden and your brain does not."

Judelson said that depending on how fast that stoppage occurs can affect brain function, though gender, age, and type of blow to the head might also play a role. Judelson said the hit could be directly to the head, or could be a body blow, or the sudden jolt of a neck, such as in a car accident; anything that causes the brain and the skull to no longer move simultaneously.

If the hit results in a concussion , symptoms typically occur rapidly, said Judelson. Some are visible and can easily be picked up by parents, coaches, athletic trainers, and even fellow players. These include balance problems, dizziness, confusion, concentration issues, double or blurry vision, and nausea or vomiting.

Other less noticeable symptoms include headaches or pressure in the head, sensitivity to light and/or sound, feeling sluggish, hazy, foggy or groggy, and just not "feeling right." Coaches should keep an eye out for players appearing dazed, confused, or unsure of position or play, as well as behavioral changes or an inability to remember what happened either prior to or immediately after the hit or fall.

Judelson said that a concussion injury boils down to a problem with energy transference inside the brain.

"On a molecular, bio-mechanical, bio-chemical neurotransmitter level, trauma leads to changes in neurotransmitters and electrolytes, and creates an energy problem, basically supply and demand," he said. "When my brain is injured, I need more blood flow. I need more energy and glucose to my brain, but because of the injury and the changes that happened, blood flow decreases to the brain and the ability to make energy decreases."

Basically, concussion symptoms occur because the brain is not able to provide the energy it needs to address the issues resulting from the trauma, Judelson said. He further explained that concussion symptoms can fall within four different categories: physical symptoms, which are the aforementioned issues most people think of - headache, dizziness, off-balance, light sensitivity, noise sensitivity.

Then there are cognitive symptoms - difficulty remembering, difficulty concentrating, feeling in a fog, generally fatigued. Sleep can also be impacted, with concussion patients either feeling extremely tired, or suffering from insomnia.

"The fourth category is an emotional category that often gets overlooked because many of the people that I see are adolescents who can be a little moody anyway," said Judelson.

He urges parents to pay attention to whether a child becomes more irritable, more anxious, more sad, or more depressed, since concussion injuries can make such behaviors worse or more pronounced. Judelson said that observations by people close to them, whether it be the coach, the teacher, teammates, classmates, or parents, are critical.

"They all know their kids better than I do," he said. "I've had plenty of parents who say, 'You know, I knew something wasn't right watching them from the stands.'That's important. You need to follow up on that."

Follow up means heading to a child's regular doctor, who may then send them to a specialist such as Judelson. Communicating their medical history, including past concussions, is important since it can offer doctors greater insight.

"With everybody who has a concussion , the most important part for me is the history and physical exam," said Judelson. "We start with what happened, what were the details, what were your symptoms, how have they changed, and then doing the examination because that helps steer what each individual person may need."

Judelson cautions that just as no two athletes are alike, no two concussions are alike.

"If we bumped into each other and both had concussions with no loss of consciousness or amnesia …Why do we both have mild concussions if I'm having severe symptoms?" he said. "There has been a thought process lately to think about clinical trajectories of each individual and their response to their concussion , because different people will have a different set of symptoms that are predominating."

That means that where one person might bounce back quickly from their concussion , another could take months to fully recover. Taking a patient's history into account, as well as their symptoms, allows doctors to create a recovery plan.

Unfortunately, the ideal means of recovery is giving the brain a break by doing very little to tax it. That can be a challenge when considering schoolwork and other responsibilities.

"Cognitive rest [is] hard to define because if you're awake there's some level of cognitive activity, and we don't generally want out kids to be in comas or completely asleep all the time," Judelson said. "The theory of, 'Oh you've got a concussion , let's go lock you away in your dark room and don't come out until you're better' doesn't always work, and often, if symptoms don't go away in a day or two, is more detrimental than anything else. So it's finding that right balance of 'what can I do, what can't I do?'" Help is dependent upon the individual, but can include varying forms of physical and occupational therapy, medication, and support strategies for coping with schoolwork. Special glasses might be necessary for concussion patients experiencing eye problems. In all cases, concussion symptoms should resolve gradually over time.

Perhaps the most significant challenge is that concussions are not preventable.

"I see a fair amount of concussions that have nothing to do with sports, that have nothing to do with anybody doing anything wrong," said Judelson.

He takes a modicum of comfort in knowing that precautionary measures are being taken.

"Football players don't practice every day in pads," he said. "They don't hit every day any more. Certainly in football [there's] the idea of teaching the right way to tackle. Trying to avoid things. It's tricky."

With sports such as soccer, Judelson said the waters are further muddied.

"There have been some movements within soccer to try and decrease the amount of heading," he said. "I don't know why all of these really good soccer players need to hit the ball with their head. It seems to me that if they took a half a step back, trapped the ball with their chest, and dribbled on, they're going to do fine. Most of the concussions that occur in soccer are in the attempt of or act of heading the ball because either you mishit it with your head or you end up hitting somebody else and not the ball. Why we need to do that, I don't know."

"I think the big piece of treating concussion is realizing that you have one, realizing that the need for rest is the most important thing," he said. "Unfortunately there's not a magic pill or magic treatment that works for everybody other than decreasing the demands that you place on your brain. I'm always encouraged when a kid tells me, 'I knew something wasn't right and I took myself out of play.' That's somebody that's gotten the last five years of everybody's education about 'you need to take these things seriously.'"